Review Jay’s medical record information. Then, answer the series of questions.
Name: Jay
Age: 72
J. G., a 72-year-old Caucasian male, has been seen regularly by you in the past. He presents for an acute care visit.
Chief Complaint: “Right side pain.”
HPI: Mr. G. reports that the right flank pain began last Thursday (3 days ago), acutely without injury. The pain, at most, is 6/10 and also occurred to the right low abdominal quadrant. Pain is consistent but variable intensity, aching pain, no aggravating or alleviating factors, no self-treatment. He has had episodic chills with pain. He also notes some inconsistent urine frequency without dysuria, urgency, or noticeable hematuria. He denies fever, nausea/vomiting, chest pain, or shortness of breath.
PMH:
• Type 2 diabetes mellitus
• Chronic kidney disease, DM nephropathy, serum creatinine range 1.2–1.5 (eGFR 40–54) over the past year
• Mild degenerative joint disease of the knees
• HTN
• Depression
Medication:
• Aspirin 81 mg po daily
• Lisinopril 40 mg po daily
• HCTZ 12.5 mg po bid
• Glipizide 10 mg po bid
• Simvastatin 20 mg po q bedtime
• Tylenol 500 mg po q 8hrs prn
• Sertraline 50 mg po daily
Social History: Mr. G. has been married for 47 years and states that he has always been monogamous. He quit smoking 6 years ago (20 pack/year history).
Lab Results:
Select each tab below to review different lab results.
CMP TEST RESULTS
CMP Test Results
Test Name Result Units Ref. Range
PHOSPHORUS 3.5 mg/dL 2.5–4.9
CALCIUM 9.1 mg/dL 8.5–10.1
SODIUM 143 mmol/L 136–145
POTASSIUM 4.2 mmol/L 3.5–4.7
CHLORIDE 105 mmol/L 98–107
CO2 27 mmol/L 21–32
UREA NITROGEN 29 H mg/dL 7–21
CREATININE 2.02 H mg/dL .67–1.17
eGFR 33 L mL/min Ref: >=60
GLUCOSE 107 H mg/dL 70–99
MAGNESIUM 2.0 mg/dL 1.8–2.4
AST, ENZ. 25 U/L 10–37
ALT/SGPT 22 U/L 10–65
TOTAL BILIRUBIN 0.3 mg/dL 0.2–1.0
ALKALINE PHOSPHATASE 83 U/L 50–136
ALBUMIN* 3.7 g/dL 3.5–5.0
PT 10.0 seconds 9.5–11.7
INR .96 0.9–1.1
CBC TEST RESULTS
CBC Test Results
Test Name Result Units Ref. Range
WBC 7.85 K/uL 4.0–11.0
RBC 4.11 L M/uL 4.2–5.7
HGB 12.3 L g/dL 13–17
HCT 37.0 L % 40–51
MCV 90.0 fL 82.0–99.0
MCH 29.9 pq 27–34
MCHC 33.2 g/dL 31–37
RDW-CV 13.6 & 0.0–15.0
PLT CT 239 K/uL 130–400
MPV 10.3 fL 8.0–12.0
UA TEST RESULTS
UA Test Results
Test Name Result Units Ref. Range
COLOR-UA YELLOW
CLARITY-UA CLEAR Ref: Clear
GLUCOSE-UA NEGATIVE mg/dL Ref: Negative
BILIRUBIN-UA NEGATIVE Ref: Negative
KETONES-UA NEGATIVE mg/dL Ref: Negative
SPECIFIC GRAVITY-UA 1.024 1.003–1.030
BLOOD-UA TRACE Ref: Negative
PH-UA 5.0 5.0–8.0
PROTEIN-UA 30 mg/dL Ref: Negative
UROBILINOGEN-UA NEGATIVE E.U./dL 0.2–1.0
NITRITE-UA NEGATIVE Ref: Negative
LEUKOCYTE ESTERASE-UA NEGATIVE Ref: Negative
RBC-UA (AUTO) 0–2 /HPF 0–2
WBC-UA (AUTO) 0–5 /HPF 0–5
SQUAMOUS-UA (AUTO) OCCASIONAL /HPF Ref: Occasional
HYALINE CASTS (AUTO) 0–2 /LPF 0–2
BACTERIA-UA (AUTO) OCCASIONAL /HPF Ref: Occasional
Physical Findings:
• General: Appears in slight pain but alert and oriented.
• VS: temp 100 F, HR 90, BP 130/80, RR 16
• Abdomen: Soft, slight tender RUQ, no masses or organomegaly. No rebound tenderness. Bowel sounds active in all quadrants. Slight costovertebral angle tenderness right.
• GU: Normal external male with circumcised penis. Testicles descended bilaterally without masses or tenderness. No hernia or regional lymphadenopathy.
• Rectal: Good sphincter tone. Prostate is slightly enlarged, firm, and nontender with no bogginess or masses. Hemoccult is negative.
Post
Post your responses to the following questions to the forum below. Your post should be a total of 500–900 words.
1. What are the most likely causes of the abnormal lab results?
2. What are your differential diagnoses for his acute complaint? Explain rationale.
3. You order a stat (quick) CT. While the patient is having the test done, his wife asks if they can return tomorrow for the results stating, ‘what’s the worst that can happen?’ Given your top two differential diagnoses, explain potential complications that can occur.
4. The CT results of the kidneys for Jay return. According to the report, CT abdomen and pelvis are unenhanced:
o Artifacts from left hip prosthesis partially obscuring the deep pelvis.
o No definite evidence of calculus formation localized to the left kidney, left ureter, or urinary bladder.
o No left hydronephrosis.
o Moderate hydronephrosis right kidney with 1.3 cm in greatest dimension single calculus lodged in distal right renal pelvis.
o No dilatation. Right ureter distal to site of obstruction. No evidence of additional calculus formation in the visualized right ureter.
o Impression: 1.3 cm nodular calculus in proximal right renal pelvis; obstructed right ureter pelvic junction resulting in moderate right hydronephrosis.
What is your treatment plan for this acute problem?
